MEDICARE: CARLY ANN CHEATHAM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	C350-1019-7862	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C350-1019-7862	OTHER	IL	STATE LICENSE

General Provider Information

NPI Number	:	1386376820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY ANN CHEATHAM

Provider Business Mailing Address
First Line	:	1500 S MISSOURI AVE UNIT 3
Second Line	:
City	:	MORTON
State	:	IL
Zip	:	61550-9028
Country	:	US
Telephone Number	:	217-706-0491
Fax Number	:

Provider Business Practice Location Address
First Line	:	4450 N PROSPECT RD STE C5
Second Line	:
City	:	PEORIA HEIGHTS
State	:	IL
Zip	:	61616-6578
Country	:	US
Telephone Number	:	309-363-7594
Fax Number	:	309-966-3621

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/24/2022
Last Update Date	:	06/24/2022

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Directions to “ CARLY ANN CHEATHAM ” Practice Location

Language	Start Address	Practice Location

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